A nurse is caring for an infant who is dehydrated and requires IV therapy. The nurse should monitor the infant's response to therapy by performing which of the following actions?
Taking the infant's vital signs every 2 hr
Counting the number of wet diapers every shift
Weighing the infant at the same time every day
Measuring the infant's head circumference twice per day
The Correct Answer is C
A. Taking the infant's vital signs every 2 hr: Monitoring vital signs every 2 hours can help assess the infant’s general condition and detect changes in heart rate and blood pressure, which can indicate changes in hydration status. However, it might not be sufficient alone to monitor fluid status.
B. Counting the number of wet diapers every shift: Tracking the number of wet diapers is an effective way to monitor the infant's fluid output and hydration status. An increase in wet diapers typically indicates improved hydration. This is a practical and non-invasive method for assessing the effectiveness of IV therapy in infants.
C. Weighing the infant at the same time every day: Daily weights are a critical measure of fluid balance in infants. A consistent daily weight check provides a direct and accurate assessment of the infant’s hydration status and response to IV therapy.
D. Measuring the infant's head circumference twice per day: Measuring head circumference is not relevant for monitoring hydration status. It is typically used to assess growth and development in infants, not fluid balance or response to IV therapy.
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Related Questions
Correct Answer is D
Explanation
A. Stand above the child's eye level when speaking: The nurse should be at eye level with the child to facilitate lip reading and better communication.
B. Talk directly into the child's impaired ear: This can be uncomfortable and is not effective. The nurse should speak directly to the child, allowing them to use any residual hearing or hearing aids.
C. Speak loudly to the child: Speaking loudly can distort the sounds and make understanding more difficult for hearing-impaired individuals.
D. Speak slowly while facing the child: Speaking slowly and facing the child ensures that they can read lips and facial expressions, which aids in understanding.
Correct Answer is C
Explanation
A. "He takes his medication between meals with water." Taking carbamazepine with food helps reduce gastrointestinal upset, but taking it between meals is not critical unless there are specific issues. This is not a priority unless the patient is experiencing significant GI discomfort.
B. "He only sleeps about 5 hours each night." Insufficient sleep can exacerbate seizure disorders, but it is not directly life-threatening. Improving sleep hygiene is important but not the most immediate concern compared to other symptoms.
C. "He seems to be getting a lot more bumps and bruises lately." Increased bruising can indicate thrombocytopenia, a potential side effect of carbamazepine, which can lead to serious bleeding issues. This is the priority as it may indicate a severe adverse effect requiring immediate medical attention and possible adjustment of medication.
D. "He has not been eating as much lately." Decreased appetite can be a side effect of many medications, including carbamazepine, but it is generally not immediately dangerous unless it leads to significant weight loss or nutritional deficiencies. It’s important but not the most urgent concern.
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